Explaining ADHD medication start, monitoring and diversion risk (CASC)

Station instructions (candidate)

You have 7 minutes. Speak with the adolescent and parent. Explain why current IR methylphenidate may be failing school coverage, propose a safer formulation or alternative, address heart and addiction fears with accurate absolute-risk language, outline monitoring (including growth and BP/HR), and set diversion-aware prescribing rules. Avoid jargon without explanation. Do not guarantee cure. Do not dismiss parental cardiac concern given family history — show how you risk-stratify.[1][2][6]

Marking domains

Empathy and agenda setting; accurate plain-language mechanism (helping attention circuits via catecholamines, not a personality drug); school coverage and long-acting rationale; diversion response to lost scripts; CV risk framing that pairs rare serious events in large studies with routine BP/HR and red-flag advice; addiction myth addressed with Wilens-era evidence without denying diversion; growth monitoring; clear follow-up and crisis contacts; offer atomoxetine pathway if they refuse stimulants.[2][3][4][5][8]

Model communication map

1. Open: thank them; check what they read online; name shared goals (school completion, less conflict, safe driving later).[6]
2. Why IR may be failing: short action windows leave afternoon lessons uncovered; twice-daily also increases lost-dose and diversion opportunities.[1][6]
3. Proposal: switch to a long-acting methylphenidate morning dose (product-specific, e.g. OROS-style starting in labelled low range and titrating) or lisdexamfetamine starting often 20–30 mg each morning with weekly titration if amphetamine class chosen — explain prodrug concept simply as "activated after absorption, harder to misuse than some short tablets."[7][1]
4. Heart talk: medicines can raise pulse and blood pressure a little on average; large studies in young people did not show a clear surge in heart attacks or strokes overall, but family heart history means we check BP/HR, ask about fainting/chest pain/exercise symptoms, and involve cardiology if red flags — we do not ignore and we do not scare without numbers.[2][3][4]
5. Addiction talk: treating ADHD with prescribed stimulants has not been shown in meta-analysis to create later substance use disorders; lost scripts are a safety issue — fewer tablets at a time, long-acting form, school nurse options if available, no sharing.[5][6]
6. If they refuse stimulants: atomoxetine is a non-stimulant option that works over weeks (not the same day), with its own monitoring for tummy symptoms, mood, and BP/HR.[8]
7. Monitoring plan: height/weight, appetite, sleep, mood, BP/HR at reviews; earlier contact if chest pain, faint, severe mood change, or requests for early repeats.[4][6]
8. Close: questions, written plan, who to call; confirm local controlled-drug pickup rules without inventing statute numbers.[6]

Common fails

• Promising zero cardiac risk or, conversely, telling them stimulants "cause heart attacks" as a universal fact.[2][3]
• Ignoring lost scripts / diversion while increasing IR supply.[6]
• Claiming atomoxetine works in 30 minutes.[8]
• Talking only to the parent and excluding the 16-year-old.